Faculty Handbook

Threat Incident Report Form

Name of Person Reporting Incident______________________________________________________________________
     
Position/Department__________________________________________________________________________________
     
Name of Victim (if different from above)__________________________________________________________________
     
Position/Department__________________________________________________________________________________
     
Date of Incident _________________ Time of Incident_______________________________________________
     
Location of Incident__________________________________________________________________________________
     
Description of Incident________________________________________________________________________________
     
__________________________________________________________________________________________________
     
__________________________________________________________________________________________________
     
__________________________________________________________________________________________________
     
__________________________________________________________________________________________________
     
__________________________________________________________________________________________________
     
Any witnesses to incident?   Yes     No
     
If Yes, Name_______________________________________________________________________________________
     
Position/Department__________________________________________________________________________________
     
Person or persons alleged to have committed offense:
     
  1. Name____________________________________________________________________________________
       
  Position/Department__________________________________________________________________________
       
  2. Name____________________________________________________________________________________
       
  Position/Department___________________________________________________________________________
     
Police Notified?   Yes     No
     
Previous threats before this incident          
or reports to police?   Yes     No
     
  If yes, explain ___________________________________________________________________
     
  ___________________________________________________________________
     
  ___________________________________________________________________
     
Did you require medical attention          
as a result of this incident?   Yes     No
     
Did you miss work as a result    
of this incident?   Yes     No
     
Was incident reported to any    
other person?   Yes     No
     
  If so, who(name/address) ___________________________________________________________________
     
  ___________________________________________________________________
     
  ___________________________________________________________________
     
     
What would you like to see done about this incident?
     
__________________________________________________________________________________________________
     
__________________________________________________________________________________________________
     
__________________________________________________________________________________________________
     
_______________________________       ___________________________________
Complainant's Signature         Date

6/99

 


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